Gout is a type of arthritis characterized by elevated uric acid levels (hyperuricemia) and the accumulation of uric acid crystals in the joints. This type of arthritis is known for its painful flares that can last up to two weeks following periods without any symptoms.
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Physical Mobility
- Impaired Sitting/Standing/Walking
- Risk for Adult Falls
Overview
Gout primarily occurs when there is an overproduction of uric acid or an underexcretion due to the kidney’s inability to eliminate uric acid, leading to hyperuricemia. Urate crystals accumulate in the joints, which are shaped like needles, triggering an inflammatory response and causing severe pain.
Gout typically presents asymmetrically and is primarily known for its occurrence in the great toe (Podagra), but it can also affect the midfoot, ankles, knees, wrists, and fingers. During acute flares, affected joints appear inflamed and are sensitive to touch.
Chronic gout is characterized by visible deposits of urate crystals (tophi) that form nodules under the skin.
Nursing Process
Gout can be effectively managed through medications and lifestyle modifications. The plan of care focuses on decreasing pain, reducing inflammation, and preventing the recurrence of attacks. Patient education is vital to avoid complications and reduce the incidence of flares.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to gout.
Review of Health History
1. Assess the patient’s general symptoms.
Gout typically occurs in a single joint but can affect multiple joints. The joints are inflamed with erythema and swelling and are sensitive to touch. The patient may experience limited mobility. Systemic symptoms like fatigue, fever, and chills may occur, though further evaluation is recommended to rule out other causes.
2. Let the patient describe the pain onset and characteristics.
In acute gout, the onset of pain is sudden and intense, often described as throbbing. Symptoms may peak around 12 hours but can last up to two weeks if left untreated. The pain is often worse at night and may wake the patient up from sleep. Even the light weight of a bedsheet is intolerable on the joint.
3. Determine risk factors.
Gout occurs more commonly in men than women. Women rarely develop this condition before menopause. The age of onset for gout is between 30-50 years, though the rate increases with age.
4. Review the patient’s medical history.
Hyperuricemia can develop due to the following medical conditions:
- Metabolic syndromes (diabetes, hypertension, dyslipidemia)
- Renal impairment
- Obesity
- Anemia
- Genetics
5. Review the patient’s medication list.
Uric acid levels can rise as a result of low-dose aspirin, anti-rejection medications for recipients of organ transplants, levodopa, and diuretics.
6. Review the patient’s diet.
Foods that are rich in purines contribute to the development of uric acid. High-purine foods include:
- Red meat
- Organ meats
- Seafood (shellfish, anchovies, sardines)
- Alcoholic beverages (especially beer)
- Sugar-sweetened beverages
7. Assess for triggers.
The following are triggers for acute gout flares:
- Alcoholic beverages
- High-purine foods
- Trauma
- Dehydration
- Certain medications
Physical Assessment
1. Inspect for signs of inflammation.
Patients typically present with symptoms in one joint (monoarticular), though polyarticular gout is possible. Assess the patient’s range of motion in the joint. Inspect all the joints for symptoms of inflammation, such as:
- Tenderness
- Erythema
- Warmth
- Swelling
2. Monitor the temperature.
Acute gout attacks can cause fever in patients (especially if they are polyarticular). Monitor for signs of infection over the joint that mimic or coexist with acute gouty arthritis.
3. Assess for tophi in chronic gout.
Long-term untreated gout may result in nodules under the skin on the affected joint that are collections of urate crystals. These nodules are firm and painless, though they may become tender during flares.
Diagnostic Procedures
1. Analyze the joint fluid results.
Arthrocentesis confirms a diagnosis of gout when fluid analysis determines the presence of urate crystals.
2. Consider uric acid levels.
Elevated serum acid levels do not necessarily confirm or rule out gout, as patients with symptoms may have normal levels, and those with elevated uric acid levels may never experience gout. Still, uric acid levels should be monitored, as it is recommended to keep levels < 6.0 mg/dL to prevent flares.
3. Obtain blood for testing.
Lab tests may be conducted to monitor for conditions that are associated with causing gout, such as:
- Renal function tests
- Liver function tests
- White blood cell count
- Triglyceride levels
- High-density lipoprotein levels
- Glucose levels
- Thyroid function tests
4. Prepare the patient for an X-ray.
X-rays do not diagnose gout but can reveal swelling early in the disease. Later findings may show a “punched-out” appearance of bone erosion.
5. Anticipate imaging to assess later findings.
Ultrasound, computed tomography, or MRI may be utilized to assess established cases of gout or monitor for complications such as tendon involvement or osteomyelitis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to gout.
Treat Acute Flares
1. Administer medications as prescribed.
Colchicine is an anti-inflammatory administered for gout flares, though it is becoming less favored based on current guidelines. NSAIDs like naproxen or indomethacin effectively manage pain. If the patient cannot tolerate either type of medication, corticosteroids may be used.
2. Apply ice.
Ice is a nonpharmacologic treatment that may alleviate gout pain and swelling.
3. Elevate the limb.
Elevate the affected extremity above the level of the heart to reduce swelling.
Prevent Gout Flares
1. Administer medications as prescribed.
Allopurinol is used to inhibit xanthine oxidase, which lowers uric acid levels. This medication may be necessary in patients with frequent gout attacks. Probenecid or febuxostat (for patients with renal impairment) are other types of hyperuricemic medications.
2. Encourage lifestyle modifications.
Weight loss in obese patients can improve uric acid levels. Encourage the patient to participate in exercise as tolerated.
3. Educate on diet modifications.
Educate patients to avoid or limit foods high in purines (red meat, beer, bacon, shellfish, soda) and focus on adding low-purine foods to their diet, including fruits, vegetables, low-fat dairy, eggs, vitamin C, and coffee. The DASH (Dietary Approaches to Stop Hypertension) diet has been shown to lower the risk of gout with the added benefit of lowering the risk of cardiovascular disease. Patients should be encouraged to drink plenty of water unless contraindicated.
4. Manage other chronic conditions.
Chronic diseases that contribute to gout, such as diabetes, kidney disease, and hypertension, must be managed appropriately to reduce the risk of gout flares.
5. Discontinue or change medications if possible.
Since certain medications can cause gout flares, review the patient’s medication list and discuss potential alternatives if possible.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for gout, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for gout.
Acute Pain
Sudden and severe pain occurring in one or more joints, usually in the big toe, is the classic symptom of gout. This occurs due to the accumulation of uric acid, forming sharp crystals in the joints.
Nursing Diagnosis: Acute Pain
Related to:
- Disease process
- Inflammatory process
As evidenced by:
- Reddened, swollen joints
- Distraction behavior
- Expressive behavior
- Guarding behavior
- Positioning to ease pain
- Limited range of motion
- Reports pain characteristics and intensity
Expected outcomes:
- Patient will verbalize pain relief and perform activities of daily living without discomfort.
- Patient will display an absence of redness, swelling, and warmth to the affected joints.
Assessment:
1. Assess pain characteristics and location.
Gout can be diagnosed during a flare when the joint is painful and swollen. It is important to identify which joints are affected to optimize the treatment plan.
2. Assess laboratory and diagnostic studies.
While the result of a physical examination can diagnose gout, laboratory values and diagnostic studies can help determine the extent of the condition. Blood tests to measure uric acid levels and x-rays can help rule out other possible causes of joint inflammation.
Interventions:
1. Administer pain medications as indicated.
NSAIDs are usually prescribed to help relieve pain and reduce joint inflammation in patients with gout. Steroids can also help reduce damage to the joints.
2. Elevate the limb.
Elevating the affected joint can help reduce inflammation.
3. Apply cool compresses.
Nonpharmacologic interventions such as the application of cool compresses and ice can reduce inflammation and soothe burning sensations.
4. Adjust lifestyle behaviors.
Gout attacks can be minimized by reducing risk factors such as the intake of alcoholic beverages, sugary drinks, and high-purine foods such as red meats and some seafood.
Deficient Knowledge
If diagnosed and managed early, patients with gout can live without constant pain, joint swelling, and sudden flare-ups. The patient’s willingness to learn about the disease condition and ways in which flare-ups and complications can be prevented is vital in the management of gout.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation
- Inadequate participation in care planning
- Inadequate access to resources
- Inadequate awareness of resources
- Inadequate commitment to learning
- Inadequate information
- Inadequate interest in learning
- Lack of information provided
As evidenced by:
- Inaccurate follow-through of instructions
- Inaccurate statements about a topic
- Nonadherence to the treatment plan
- Recurrent gout attacks
Expected outcomes:
- Patient will be able to explain the disease process and the importance of compliance with the treatment regimen.
- Patient will specify two diet recommendations to prevent gout.
- Patient will verbalize their medication regimen to treat gout.
Assessment:
1. Assess the patient’s understanding of the current condition.
Determining the patient’s knowledge about gout can help assess learning needs about the condition, its prognosis, and interventions.
2. Assess the patient’s motivation to learn.
The patient’s readiness to learn about the condition and motivation for improved symptoms can affect patient education efforts and outcomes.
Interventions:
1. Educate the patient about the importance of proper nutrition.
Since gout can be aggravated by food choices, provide the patient with verbal and written foods that should be avoided (red meat, bacon, organ meats, sardines) and foods that should be increased (water, vegetables, whole grains).
2. Refer to a rheumatologist.
Gout is a form of arthritis that is often managed by a rheumatologist. If a patient is struggling with controlling their gout, they may need the expertise of a specialist.
3. Explain the importance of pharmacologic treatment for gout.
Colchicine is a common medication for gout pain. Medications such as allopurinol block uric acid production. Educate the patient on how to safely administer OTC medications for pain.
4. Educate on chronic conditions.
Patients may not realize risk factors such as diabetes, heart disease, and renal disease contribute to the build-up of uric acid and gout. Discuss how controlling these conditions will reduce the incidence of gout attacks.
Impaired Physical Mobility
Patients with gout often find it difficult to walk or stand when they are having flare-ups in their feet, knees, or ankles because of severe and sudden pain and swelling. When there is joint swelling, the joints can become stiff, and painful when moved, and the range of motion will become more limited.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Pain
- Inflammatory process
- Limited range of motion
- Joint tenderness
- Joint stiffness
As evidenced by:
- Altered gait
- Decreased range of motion
- Difficulty turning
- Expresses discomfort
- Postural instability
- Slowed movement
- Spastic movement
- Uncoordinated movement
- Hesitancy to move
Expected outcomes:
- Patient will be able to ambulate with minimal discomfort.
- Patient will participate in activities to improve their range of motion.
Assessment:
1. Assess the extent of joint pain and inflammation.
It is critical to assess the extent of pain and inflammation of affected extremities and joints to help determine the effects on the patient’s quality of life and formulate a treatment plan for optimal results.
2. Assess diagnostic studies and their results.
A synovial fluid analysis may be indicated to help determine the presence of crystals in affected joints.
Interventions:
1. Encourage weight loss.
Obesity places extra stress on joints and also increases the incidence of diabetes, hypertension, and other chronic conditions that are risk factors for gout. Patients should work towards 150 minutes per week of moderate physical activity.
2. Encourage active and passive ROM exercises.
Range of motion exercise can help preserve the flexibility and mobility of affected joints. Gout causes joint stiffness and patients can be provided with exercises they can do themselves or with someone else to maintain their mobility.
3. Refer to PT or OT.
A physical therapist or occupational therapist can help evaluate the extent of impaired physical mobility in patients with gout. Also, they can formulate a plan that promotes strength training and gait training, placing special attention on the affected joints and extremities.
4. Encourage the use of mobility aids when necessary.
Mobility aids like handrails, canes, and shower benches promote patient safety during gout flare-ups and prevent accidental falls and other injuries.
5. Protect the joints.
Exercise is recommended but joint injuries can occur if they are overextended. Choose low-impact activities such as swimming and biking.
Impaired Sitting/Standing/Walking
Patients with gout often have problems with mobility, like walking, sitting, and standing, due to painful flares in joints of the knees, ankles, feet, and toes, which can last days or longer.
Nursing Diagnosis: Impaired Sitting/Standing/Walking
Related to:
- Disease process
- Joint pain
- Inflammation
- Limited range of motion
- Tophi (chronic uric acid deposits)
As evidenced by:
- Inability to bear weight
- Difficulty attaining postural balance
- Hesitancy in moving
- Slowed movement
- Impaired ability to walk a required distance
- Impaired ability to extend/flex affected joint
Expected outcomes:
- Patient will demonstrate independence and safe movement when sitting, walking, and standing.
- Patient will be able to ambulate or change positions without discomfort.
Assessment:
1. Assess and monitor joint pain and inflammation.
Gout can affect the patient’s mobility due to joint pain and inflammation. Assess the severity of the pain, redness, and swelling to plan appropriate interventions.
2. Assess the patient’s baseline level of physical functioning.
The nurse should assess the patient’s usual mobility level when not experiencing a gout flare to understand the impact of gout symptoms on their activities.
3. Assess the patient’s range of motion.
Gout may affect the patient’s range of motion in the joint. The nurse can assist with passive movement of the joint to assess for pain and limitations.
Interventions:
1. Encourage joint-friendly activities between flares.
Exercise can aid in weight loss and overall health, which may reduce gout flares. Joint-friendly activities like cycling, walking, and swimming do not put too much stress on the joints.
2. Ensure proper footwear.
The patient should wear comfortable and supportive footwear. Specialized footwear can assist with proper joint alignment and gait to decrease pressure on the joints.
3. Encourage rest during flares.
Rest is recommended when experiencing a flare. Advise the patient to elevate the affected limb and apply ice to relieve pain and swelling.
4. Encourage the use of mobility aids when needed.
Mobility aids like canes may be needed for severe gout symptoms to reduce pressure on the joints while maintaining mobility.
Risk for Adult Falls
Since gout makes it difficult for the patient to bear weight due to joint swelling, pain, and tenderness, it increases the risk of falls and injuries.
Nursing Diagnosis: Risk for Adult Falls
Related to:
- Disease process
- Inflammatory process
- Joint swelling
- Joint tenderness
- Joint pain
- Impaired physical mobility
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free of falls.
- Patient will verbalize strategies to decrease their risk of falls during a gout flare.
Assessment:
1. Assess the patient’s balance and mobility skills.
It is vital to determine the patient’s functional abilities as this can help determine problem areas that increase the patient’s risk for falls and injuries and plan out interventions to ensure patient safety.
2. Assess factors that contribute to the patient’s increased risk for falls.
While gout symptoms increase the patient’s risk for falls, other factors, such as advanced age, poor vision or hearing, certain medications, and other conditions affecting mobility, can also contribute to this risk.
Interventions:
1. Encourage the use of mobility aids as indicated.
Mobility aids like walkers, canes, crutches, and wheelchairs are useful for patients during gout flares who are at risk for falls.
2. Educate on activities to improve balance and posture between flares.
Yoga, tai chi, and specific exercises can be practiced in between flares to improve posture, balance, and weakness to reduce the risk of falls when flares occur.
3. Limit activities during flares.
If possible, it may be recommended for the patient to refrain from using stairs or walking long distances during a flare to reduce the incidence of a fall.
4. Administer pharmacologic and nonpharmacologic therapy.
Pain can affect the patient’s mobility and may further increase the patient’s risk for falls. NSAIDs, ice, and rest can reduce symptoms until the flare subsides.
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